GW1--02880_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: i ,
Spencer Adams l4:wATERzoNEs ,
Well Contractor Name FROM TO DESCRIPTION
4449-A 240 ft. 260 ft. 2 GPM{
380 ft. 420 ft. 2 GPM{
NC Well Contractor Certification Number 15:OUTER CASING(for:multi-cased:weul):ORLINEK(f In tteable}'•• '.' ' • :
Rowan Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
co Name 0 ft. 78 it. 61/41 in• SDR21 PVC
OSWP20234892I .16.INNER CASING-OR TIMING(ge ermalclosed.oep):. :.::
2.Well Construction Permit II: FROM TO DIAMETER THICKNESS MATERIAL
Liston applicable well construction permits(Le.UIC County,State,Variance,etc.) ft. ft. i hi.
3.Well Use(check well use): ft. ft. in.
Water Supply Wells 17:SCRBEN
FROM TO DIAMETER SLOT SITS THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft, R. in..
Geothermal(Heating/Cooling Supply) x°Residential Water Supply(single) ft. It. in.!.
Industrial/Commercial °Residential Water Supply(shared)
Irrigation FROM TO MATERIAL .EMPLACLMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. F2SealSlurry Pump 10
Monitoring °Recovery ft. R.
Injection Well:
Aquifer Recharge °Groundwater Remediation
,19:HAND/GRAVEL PACK(if applicable) :, •: :`` •:
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stem:water Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'(attacti additions lsheets'if tiecessaryy).;'.'. .. : -
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(eelo.e.raaes..so0h«IctvpG Rr>In etc.)
4/19/24 202448921 0 � 20 ft. Clay I
4.Date Well(s)Completed: Well BM 20 60 Sandy Overburden
5a.WellLocation: 60 ft. 68 ft' Weathered Rock
Northlake Developers 68 ft. 78 fa Solid Rock
Facility/Owner Name Facility MD(if applicable) 360 f4 400 fA Brown veins/broken rock
154 Fox Hunt Dr, Mooresville 28117 f. ft.
Physical Address,City,and Zip ft. ft. : ? :,
Iredell 4639 231668 27C12EMARIC3:.`.. d:.�: :;�. . . aa'
County Parcel Identification No..(PIN) MAY 1 0 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) ! f-:-;^s,;,'�r. P-:-.r-,.^v;;^,:tea r.
22, ertlficetlon: r,..,. L'ti:)£
35 38 26.847 N 80 54 42.274 w { :Vc � ',a `t'
6.Is(are)the well(s)1x Permanent or °Temporary Signature o Certified Well Contractor Date
By signing this form,I hereby rest fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or x)No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knmwr well construction information and explain the nature of the cop,ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn.
23.SIte diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:) SUBMITTAL INSTRUCTIONS!.
9.Total well depth below land surface:625 (It) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a,200'and 2@100) construction to the following.
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition to sending the fort to the address in 24a
Rota above,also submit one copy of this:form within 30 days of completion of well
12.Well construction method: construction to the following: f
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,tUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mali Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)4 Method of test:Weir 24c.For Water Sumaly&Infection Wells: In addition to sending the form to
chlorine 1.751bs the addiess(es) above, also submit,one copy of this form within 30 days of'
136-Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form taw-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016